OMG! My life belongs to a Medicare HMO!!! (First in a series, unfortunately)

If there’s one thing everybody knows about those of us who have body parts replaced, it is that we have to stay on anti-rejection meds the rest of our lives. One slip and our immune systems go haywire and try to expel the alien organ. Rejection is NOT fun: you get two grams (yes grams) of a IV form of prednisone (Solumedrol) dumped into your veins, lose what little is left of your immune system and go stark raving bonkers in the meanwhile. I’ve seen people in 9 Long – the transplant floor of UCSF’s Moffitt Hospital – suffering through this madness. They don’t mess up their rejection meds again.

Hold that thought. We’ll be right back to it.

When I was being evaluated at UCSF for my own liver transplant, if and how it would get funded was a real worry. I ignored the worry for a while – there were the million evaluation tests to get through, a chemoembolization to shrink the tumor they’d found, etcetera. But eventually the financial fretting took over: What if, after going through all the steps, the insurance company said no? One of the doctors evaluating me suggested I talk to a UCSF financial counselor.

“Don’t worry!” said the counselor. “The insurance company will likely want a second opinion and that’s normal. But you shouldn’t have any trouble getting approved.”

“How do you know?” I asked. “Heck, how will I know? I haven’t heard word one from HealthNet’s HMO since the tumor. What if I go through all these tests, you find me a liver, and HealthNet goes, ‘Oops! Sorry! Can’t afford your transplant, we have a bottom line and you’re not in it.'”

“Are you getting regular care here?” He asked.

“Yes.”

“Then things are going ok.” I looked at him puzzled. “Believe me,” he said. “We wouldn’t be doing anything for you if the insurance company wasn’t funding it.”

Nice, that.

Obviously I made it through the approval, a liver was found, and the transplant happened, all without a peep from HealthNet. I was as amazed by their silence as I was by having my body ripped open and an organ replaced. Transplants, especially liver, are expensive (there’s a lot of cutting and pasting involved in switching livers) usually to the tune of $400,0000 to half a mil. And the insurance company never squeaked? Wow.

A few weeks later, I’m out of the hospital recovering well (this is before my other complications set in) and I go to fill my prescriptions for the anti-rejection meds. Denied, said the pharmacy. Not part of HealthNet’s formulary, it seems. Medications deemed not necessary, it seems.

Huh?

And here we are, back at this post’s start. I had a transplant. The hospital staff beat me over the head making sure I understood that if I didn’t take my meds the organ – me too incidentally – is toast. And everybody knows etc., etc.; surely ‘everybody’ includes health insurance companies too? How could HealthNet not even squeak about dropping $400k for the part swap but now balk at a few hundred dollars for the meds needed to keep it functioning? Huh? Huh?

After much back-and-forth between UCSF and HealthNet it was decided that, yes, a transplant recipient probably does need anti-rejection meds and they were duly authorized. End of story? Oh, no.

Fast forward to today (Feb 08), post transplant 18 months and counting. Into the pharmacy I go to pick up my monthly supplies. My Myfortic, one of my anti-rejection meds, has gone from $7 copay to $170.

“Why?” I asked.

The pharmacy didn’t know and suggested I call HealthNet. I call, wind through the “press 1 for life, 2 to die on hold” nonsense, get a human and after much back and forth, learn that Medicare and the HMO, now working together (isn’t that a marriage made in hell), have de-authorized all rejection meds for 2008. I am out of “Huh’s?” at this point though other words that came to mind.

There is a happy ending here of sorts. Just as UCSF has a person dedicated solely to deal with financing transplants so it has a person whose job is to make sure those same companies don’t cut off transplantee’s meds after the transplant’s done. Seems I’m not the only one with this problem. I called her – we’re on a first name basis now – and after 24 hours HealthNet decides that I probably do need anti-rejection meds and probably will for the foreseeable future – at least mine. My UCSF contact was jubilant. “I told you,” she said. “HealthNet is one of the easiest to deal with.”

Sheesh. God may bless America, who knows (I have my doubts). But she clearly forgot to include our health care system.

This entry was posted on Saturday, February 16th, 2008 at 9:18 am and is filed under Health. You can follow any responses to this entry through the RSS 2.0 feed.
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Essays

Fifty at Ten Thousand FeetWhen I turned 50, I celebrated (mourned?) by repeating a favorite hike to Mono Pass on the eastern edge of Yosemite. This time, I added the descent through Bloody Canyon to the high desert to the east. The hike gave me more than I expected.